India takes its anganwadi, frontline women health workers for granted – at great cost to itself

Anganwadi workers and accredited social health activists, commonly known as ASHAs, who work on the frontlines providing basic healthcare and nutrition to India’s vast rural population, have recently been in the news because of their demands for better pay and work conditions. There have been reports of strikes and demonstrations from across the country – in Delhi, Uttar Pradesh and Nagaland – in the last few weeks. Earlier this year, thousands of them from 11 states gathered at Jantar Mantar in Delhi to bring their demands to the Central government’s attention.

For the sake of the beneficiaries (mostly women and children) of the various government programmes they work for, and in response to their very genuine grievances, these workers (mostly women) deserve greater attention both from the media and the state and Central governments. We must remember that this army of women workers plays a crucial role in helping India achieve its health and nutrition goals. It is also by providing adequate services through them that the government and society can move towards reducing, recognising and redistributing the burden of unpaid care work that women in India disproportionately bear. Elimination of hunger, reducing maternal and child mortality, and recognising unpaid care work are all part of the United Nations’ Sustainable Development Goals that India has endorsed.

Women who work as anganwadi workers, anganwadi helpers, ASHAs and mid-day meal cooks represent the lowest rung in the hierarchy of the schemes they work for – the Integrated Child Development Services that provides food, preschool education and primary healthcare for children under six and their mothers, the National Health Mission that addresses the health needs of under-served areas, and the Mid-Day Meal Scheme that provides free lunches to schoolchildren. They are also closest to the community and the beneficiary. They are the ones who actually deliver the services and the entire system above must be such that they are facilitated to do their jobs well. Unfortunately, the situation is just the opposite.

Dismal work conditions

There is hardly any supportive supervision available to help these workers deal with the challenges they face on the ground. The supervisory staff are themselves overburdened and other than routine stock-taking, maintaining of accounts and so on, they are also called upon to do other administrative work. Under the Integrated Child Development Services, about 30% of the posts of supervisors to anganwadi workers are vacant.

The workers also face harsh work conditions – many anganwadi centres and schools do not have kitchens while some of these centres do not even function out of proper buildings, and medicines, supplementary nutrition, pre-school kits and funds are in short supply. Since they are the face of the programme, the workers are often blamed by the community for the poor quality of services. Anganwadi workers have a long list of responsibilities such as providing counselling for behaviour changes in health and nutrition practices, growth monitoring, maintaining records (including registration of births and deaths), providing pre-school education, distributing supplementary nutrition and so on. ASHAs, similarly, have many roles to play, including creating awareness on health and its social determinants, promoting good health practices, counselling women on reproductive health, mobilising and facilitating the community in accessing health services and being a depot-holder for essential medicines. Each of these services that these women provide is essential and cannot be done away with.

Volunteers, not workers

Despite their role in providing critical services, the government does not consider these women as workers. Instead, they are supposed to be honorary workers volunteering their time for the community. This means that they are paid measly amounts (not even minimum wages) and their salaries are often delayed. Their monthly wages range from Rs 1,000 for cooks to a central norm of Rs 3,000 for anganwadi workers, with many states adding to this amount. ASHAs are not even paid a monthly wage but are given incentives for the various tasks they do. It is estimated that they earn on an average Rs 2,000 to Rs 2,500 a month.

In a survey on the implementation of the Integrated Child Development Services in six states in 2014, the Centre for Equity Studies found that one-third of anganwadi workers did not receive their salaries on time and 40% had to use their own funds to ensure the smooth functioning of the anganwadi centres. In the case of mid-day meal workers, self-help groups often had to take loans from the market to continue with the meals because their payments as well as the funds for the raw materials were delayed.

With declining social sector budgets, especially following the recommendations of the 14th Finance Commission in 2015, the scheme workers have been hard hit. The budget for the Integrated Child Development Services, for example, has gone down compared to three years ago. A report by the government policy think tank Niti Aayog in October 2015 even recommended a cap on the Centre’s contribution to the salaries/remuneration of ASHAs, anganwadi workers and contract teachers. So, while on the one hand the government regularly updates the salaries of the most privileged of its employees through inflation-indexed dearness allowances and pay commissions, on the other, the right to a decent wage that is at the very least indexed to inflation is denied to those who are working for it at the grassroots level.

Moreover, this abdication of responsibility by the Centre by passing the buck to the states when it comes to these important centrally-sponsored schemes is resulting in widening gaps in the quality of services provided across states. In relation to the payment of wages to frontline workers, a wide variation has been seen with states such as Tamil Nadu and Telangana paying Rs 6,000 to Rs 7,000 over and above what the Centre contributes while Bihar and Uttar Pradesh add Rs 1,000 or less. So, for the same work, an anganwadi worker in Telangana is paid more than double the amount her counterpart in Uttar Pradesh gets. The states that do not increase these workers’ salaries are also the ones that spend relatively less on other components of the programme, such as supplementary nutrition. They are also among the country’s poorest states with the worst indicators for malnutrition and health, who therefore require the highest investment in these sectors.

60-lakh-strong workforce

While these frontline workers are among the most vulnerable within the government system, they do have strength in numbers. Almost 28 lakh anganwadi workers and helpers run anganwadi centres under the Integrated Child Development Services, more than 10 lakh ASHAs and urban social health activists or USHAs are appointed by the National Health Mission, and over 25 lakh mid-day meal cooks and helpers across the country prepare fresh, hot cooked meals for over nine crore children in primary and upper-primary classes under the Mid-Day Meal Scheme. Around 60 lakh women in India work as scheme workers for these three government programmes – more than the number of employees the Indian Railways or even the Indian Army have.

The tasks they contribute to are vitally important for nation building and the future of this country. Together, they can also become a powerful voice for the rights of women workers and for bringing recognition to the unpaid care work done by women. Giving them decent wages, recognising them as regular workers and improving their working conditions are central to any effort to improve health and nutrition services in the country. Also, in a country where the female workforce participation rate is declining, hiring women in these sectors could go a long way in encouraging the employment of women.

Respecting frontline workers is an important step towards providing quality health and nutrition services. Giving these workers their due is not just a matter of workers’ rights, it is also about the rights of the most vulnerable women and children. A number of other reforms are required to improve the quality of public services for these groups. Improving the quality of the programme would result in a better work environment. While all of this would require greater investment, what needs to be considered is the cost of inaction – malnutrition and ill-health will prove costly for the economy in the present and in the future through their impact on productivity and, therefore, national income.

Dipa Sinha teaches at the School of Liberal Studies, Ambedkar University, Delhi